Page:United States Statutes at Large Volume 103 Part 3.djvu/189

 PUBLIC LAW 101-239—DEC. 19, 1989 103 STAT. 2257 42 USC 1320C-3 n ote. (d) DATE OF REPORT.—The results of the study shall be reported to Congress and the Secretary of Health and Human Services no later than December 31, 1990. SEC. 6224. PEER REVIEW ORGANIZATIONS. (a) PEER REVIEW OF NON-PHYSICIAN SERVICES.— (1) IN GENERAL. —Section 1154(a)(l) of the Social Security Act (42 U.S.C. 1320c-3(a)(l)) is amended by adding at the end the following: "If the organization performs such reviews with respect to a type of health care practitioner other than medical doctors, the organization shall establish procedures for the involvement of health care practitioners of that type in such reviews.". (2) EFFECTIVE DATE. —The amendment made by paragraph (1) shall apply to contracts entered into after the date of the enactment of this Act. (b) PROVIDER AND PRACTITIONER RIGHT TO RECONSIDERATION OF PRO DETERMINATION BEFORE NOTICE TO BENEFICIARY.— (1) IN GENERAL. —Section 1154(a)(3) of the Social Security Act (42 U.S.C. 1320c-3(a)(3)) is amended— (A) in subparagraph (A), by striking "subparagraph (B)" and inserting "subparagraphs (B) and (D)", (B) in subparagraph (B), by inserting "with respect to services or items disapproved by reason of subparagraph (A) or (CJ) of paragraph (1)" after "under subparagraph (A)", and (CD) by adding at the end the following new subpara- graphs: "CD) The notification under subparagraph (A) with respect to services or items disapproved by reason of paragraph (I)(B) shall not occur until after— "(i) the organization has notified the practitioner or pro- vider involved of the determination and of the practition- er's or provider's right to a formal reconsideration of the determination under section 1155, and "(ii) if the provider or practitioner requests such a re- consideration, the organization has made such a reconsider- ation. If a provider or practitioner is provided a reconsideration, such reconsideration shall be in lieu of any subsequent reconsider- ation to which the provider or practitioner may be otherwise entitled under section 1155, but shall not afTect the right of a beneficiary from seeking reconsideration under such section of the organization's determination (after any reconsideration re- quested by the provider or physician under clause (ii)). "(E) In the case of services and items disapproved by reason of paragraph (1)(B), the notice to the patient shall state the follow- ing: 'In the judgment of the peer review organization, the medical care received was not acceptable under the medicare program. The reasons for the denial have been discussed with your physician and hospital.*. ". " (2) CONFORMING AMENDMENT.— Section 1155 of such Act (42 U.S.C. 1320C-5) is amended by inserting ", subject to section 42 USC 1320c-4 1154(a)(3)(D)," before "any practitioner or provider". «> (3) EFFECTIVE DATE. —The amendments made by this subsec- s. - t ion shall apply to determinations by utilization and quality control peer review organizations with respect to which prelimi- 42 USC 1320C-3 note.

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